White Oak Manor - Burlington

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

55.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 160 beds and averages 114.9 residents a day — about 72% occupied, or roughly 45 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.51 hrs/resident/day on weekends vs 4.16 on weekdays — 16% thinner on weekends. RN hours go from 0.59 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 16 most serious are shown; the remaining 7 are one tap away and print in full.

• Immediate jeopardy · K2025-03-31 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, Physician, and Nurse Practitioner, the facility failed to ensure the physician was notified when Resident # 3 was initially identified by Nurse Aide # 5 to have discomfort with positioning, swelling, and bruises on his arm and chest with no known cause and while the resident was not receiving an anticoagulant. The physician was not notified until the following shift. When Resident # 3's physician was notified and a complete assessment was conducted, multiple bruises were found on both arms and the resident's chest which was a broader area than had been reported by Nurse Aide # 5 when she identified bruising. The bruising was irregular in shape and included both red and purple bruising. Two days following the initial identification of the bruises, the resident was transferred to the hospital ED (Emergency Department) where A CT (computerized tomography) of the chest abdomen and pelvis with contrast was completed. The CT impression read, 1) large left subpectoral…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-03-31 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to implement their abuse policy for employees who worked in the capacity of a licensed nurse by not screening and verifying Employee #1's credentials prior to hiring her as a licensed nurse and allowing her to perform licensed nurse duties for which she had no documented education or nursing license. Employee #1 provided the facility nurse license information for an individual she found online with a name that was similar to her own and she worked at the facility in the role of a licensed nurse from 11/5/24 until her termination on 2/6/25. During this timeframe, Employee #1 had resident assignments and performed licensed nurse responsibilities that she was not qualified to provide. On the shift that started on 11:00 PM on 12/17/24 Employee #1 was assigned to Resident #3, who was not on an anticoagulant (blood thinner) when she identified bruising to the resident's shoulders with no known cause. Employee #1 was responsible for assessing the resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-03-31 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews with staff, physician, and Nurse Practitioner, the facility failed to ensure Resident # 3 was initially assessed by a nurse after Nurse Aide # 5 identified the resident to have discomfort with positioning, swelling, and bruises on his arm and chest with no known cause and while the resident was not receiving an anticoagulant. When Resident # 3's was assessed the following shift by the physician multiple bruises were found on both arms and the resident's chest which was a broader area than had been reported by Nurse Aide # 5. The bruising was irregular in shape and included both red and purple bruising. The bruises continued to spread and two days following the initial identification of the bruises, Resident # 3 was seen in the ED (Emergency Department) where a CT (Computed Tomography) of the chest abdomen and pelvis with contrast was completed. The CT impression read, 1) large left subpectoral hematoma (a collection of blood, usually clotted, outside of a blood vessel)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-03-31 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and staff and Physician interviews the facility failed to have a system in place to ensure staff who were hired as nurses were trained and competent to perform their job duties. Employee #1, who was not licensed as a nurse and had no documented nursing education, worked at the facility in the role of a licensed nurse from 11/5/24 until her termination on 2/6/25. Her job duties included, but were not limited to: insulin administration, blood sugar monitoring, medication administration, assessments of a resident who sustained falls while on an anticoagulant (blood thinner), and utilizing nursing judgement to make decisions. These job duties required knowledge and education to perform safely. There was no documented competency evaluation completed for Employee #1's job duties or nursing skills. On the nursing shift which began at 11:00 PM on 12/17/24 Employee #1 was assigned to Resident #3, who was not on an anticoagulant, when she identified bruising to the resident's shoulders with no known cause. Employee #1 was responsible for assessing the resident and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-03-31 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview with residents, staff, Physician, and Nurse Practitioner the facility failed to protect Resident #3's right to be free of an injury of unknown source; and abuse/neglect. Resident # 3, who was a cognitively impaired resident, was identified to have significant bruises on his arm and chest which wrapped around his torso on 12/18/24. The bruises were also accompanied by swelling and discomfort with positioning when initially found. Staff reported they had not observed any incident which had caused the bruises. The resident could not provide detailed information about how the bruises occurred, and the extent of the bruising without a known cause indicated a suspicion of neglect or abuse. Also, Resident # 3 was under the care of a non-licensed employee (Employee # 1), who was working at the facility under the false pretense she was a nurse when the bruises were found. The bruises continued to spread and on 12/20/24 Resident # 3 was evaluated at the local hospital ED…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 5 residents reviewed for physical abuse. Resident #84 was sent to the emergency room for evaluation due an injury. Resident #84 was hit in the mouth resulting in treatment with Dermabond on his upper lip and a referral was sent to the dentist due to missing tooth on the resident's bridge. (Resident # 84). The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses of neurogenic bladder, cognitive communication deficit, gastrostomy, chronic kidney disease, diabetes, and wounds on the heels. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #82 was severely cognitively impaired. Review of Resident #82's care plan dated 10/25/23 revealed the focus area that Resident #82 was at risk for behaviors: socially inappropriate/disruptive behavior by voicing thoughts of self-harm related to neurocognitive disorder and history of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-18 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop a baseline care plan that addressed the resident's immediate needs related to a diagnosis of post-traumatic stress disorder (PTSD) for 1 of 1 resident reviewed for mood and behavior (Resident #125). The findings included: A review of the discharge summary from Resident #125's previous facility revealed he was discharged on 9/12/25 with diagnoses that included PTSD. The discharge summary from the previous nursing facility did not document any information regarding residents' history of past trauma or triggers that may cause re-traumatization. Review of the FL2 (a North Carolina Medicaid form that documents a patient's medical condition and needs for long term care facilities) completed 9/12/25 revealed Resident #125 had a diagnosis of PTSD. Resident #125 was admitted to the facility on [DATE] with a diagnosis of PTSD. Review of the baseline care plan dated 9/12/25 completed by the Minimum Data Set (MDS) Nurse revealed no goal or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-18 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff and resident interviews, the facility failed to follow therapy recommendations to apply a soft hand splint for 1 of 4 sampled residents (Resident #3) reviewed for positioning and mobility.The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included a left-hand contracture. The Occupational Therapy (OT) Discharge summary dated [DATE] revealed Resident #3 had a left-hand contracture. The OT discharge recommendations stated Resident #3 was to be followed by Restorative Nursing with a goal that included Resident #3 would apply and wear a left-hand splint 4-6 hours daily. Review of Resident #3's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and had one upper extremity impairment. An interview and observation were conducted with Resident #3 on 9/22/25 at 3:36 PM. Resident #3's left hand was observed to have 4 fingers and thumb tight into a fist. A blue, soft resting hand splint was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-31 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview and Physician Interview the facility failed to complete a thorough investigation related to unexplained swelling, discomfort, and bruising Resident # 3 experienced although there had been no reported accident and the resident was not on an anticoagulant. Review of the facility's completed investigation revealed the facility 1) failed to identify a hospital CT (computerized tomography) showed the resident's bruising extended to his hip area which they had not identified in their investigation 2) failed to investigate discrepancies further which were noted by reviewing Employee # 1's statements with other employees' statements and the resident's record and 3) failed to further question and clarify who had obtained a weight on the resident during the shift when the injuries were first identified in order to determine if something had happened while the resident was weighed. The findings included: Resident # 3 was admitted to the facility on [DATE]. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-01 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of a controlled substance medication, oxycodone, which was prescribed for Resident #9 and a combination medication containing oxycodone and acetaminophen prescribed to treat pain which was prescribed for Resident #225. The facility also failed to protect a resident's right to be free from the misappropriation of a bottle of alcohol prescribed for the resident (Resident #42). This occurred for 3 of 3 residents reviewed for misappropriation of property. Findings included: 1. Resident #9 was readmitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was admitted on [DATE]. The assessment indicated the resident was assessed as cognitively impaired. Resident #9 had an order dated 12/9/23 for oxycodone 5 milligrams (mg) every 6 hours. Review of Resident #9's Medication Administration Record (MAR) for January 2024…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-01 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record reviews, the facility failed to follow their policy on Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents to maintain documented evidence of a thorough investigation of an allegation of abuse for 1 of 5 residents (Resident #175) reviewed for abuse and of an allegation related to the misappropriation (diversion) of medication for 1 of 3 residents (Resident #225) reviewed for the misappropriation of property. The facility also failed to implement measures to prevent further potential for abuse and maintain documented evidence of the corrective action taken after the misappropriation was verified (including whether more systemic actions were necessary to prevent recurrence of the situation) during these investigations. In addition, the facility failed to implement their policy in the areas of reporting by not submitting the Initial and Investigation Report to the State Regulatory Agency after the facility became aware of a bottle of alcohol prescribed for the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review and staff interview the facility failed to label and date foods brought in by resident's family member and failed to maintain the nourishment refrigerators clean for 3 of 3 Nourishment refrigerators (Nourishment refrigerator #1, Nourishment refrigerator #2 and Nourishment refrigerator #3). The facility failed to maintain the ice scoop clean in 1 of 3 nourishment rooms (C wing Nourishment room). These practices had the potential to affect food served to residents. Findings included: Review of the policy Food Brought into facility for resident revealed foods should be stored in clean, sealed air-tight containers in the refrigerator. The container should be labeled and dated. The policy indicated the food may be stored in the refrigerator for up to 3 day. Foods improperly stored or labeled or stored for more than 3 days would be discarded by the nursing staff. 1 a. Observation of the nourishment refrigerator #1 (B Wing) on 7/29/24 at 10:13 AM, revealed a plastic grocery bag with takeout food container with no label or date. A plastic bag containing a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to provide nail care to a resident dependent on staff. This occurred for 1 of 4 residents (Resident #16) reviewed for activities of daily living (ADL) care. The findings included: Resident # 16 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of the recent admission Minimum Data Set (MDS) assessment, dated 6/18/24, revealed him as having intact cognition. The resident required extensive assistance with activities of daily living (ADL), including personal hygiene. He had no behaviors or rejection of care. Review of the plan of care, dated 7/11/24, revealed that Resident #16 had ADL selfcare performance deficit, with goals and interventions, including for staff to provide assistance with bathing and personal hygiene. On 7/29/24 at 11:05 AM, during the observation/interview, Resident #16 was in bed, dressed and groomed. His bilateral fingernails were observed to be long (approximately one inch…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-01 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with the Responsible Party and facility staff the facility failed to ensure 1 of 1 resident (Resident #76) was transported to a scheduled oncology follow-up appointment. Findings included: Resident #76 was admitted to the facility on [DATE] with diagnosis of dementia and cancer. Review of Resident #76's medical record revealed she had a Physician's Order for Anastrozole one milligram once daily for chemotherapy related to breast cancer. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #76 was severely cognitively impaired. During an interview with the Responsible Party on 7/29/2024 at 11:29 am he stated Resident #76 was not transported to a previously scheduled oncology appointment for follow-up for breast cancer on 2/6/2024. The Responsible party stated Resident #76 was taking an oral chemotherapy drug and saw the oncologist for follow-up, but the facility failed to have her at the appointment as planned. The Responsible Party stated he called the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-01 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and consultant pharmacist interviews and record reviews, the facility failed to: 1) Maintain documentation of the pharmacist's Monthly Medication Reviews (MMRs) within the facility and readily available for review; and 2) Retain documentation of the physician's review and response to the pharmacist's findings / recommendations in the resident's medical record. This occurred for 1 of 5 residents reviewed for Unnecessary Medications (Resident #20). The findings included: Resident #20 was initially admitted to the facility on [DATE] with re-entry on 12/26/23 from a hospital. Her cumulative diagnoses included epilepsy, anxiety disorder, dementia, and mild neurocognitive disorder (a collection of syndromes in which the primary clinical feature is a decline in cognitive functioning) with behavior disturbances. A review of the resident's electronic medical record (EMR) revealed a medication order was received on 12/26/23 for 2.5 milligrams (mg) olanzapine (an antipsychotic medication) to be given as 1…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-06-07 · tag F0728 — failed to protect against nurse-aide misconduct — isolated
  Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure staff who performed a job responsibility of a nurse aide (NA) had completed a training and competency evaluation program and was competent to provide nursing and nursing related services when the Maintenance Director assisted NA #2 with transferring Resident #1 from her wheelchair to bed utilizing a mechanical lift on 5/16/24. This deficient practice was for 1 of 7 staff reviewed who performed nursing related services. The findings included: Resident #1 was admitted to the facility on [DATE]. An interview was conducted on 6/05/24 at 1:45 pm with the Activity Assistant who revealed that during the late afternoon on 5/16/24 she observed the Maintenance Director operate the mechanical lift to put Resident #1 in bed. She reported she was not sure if another staff member was present with the Maintenance Director at the time of the observation because the privacy curtain was pulled. The Activity Assistant stated she also worked as a NA at the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$137,472 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $109,668 — penalty dated 2025-03-31
• $27,804 — penalty dated 2024-06-07
• Medicare payment denial — starting 2025-04-23 for 2 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC